Wound Care Interventions Kate McKenney PT CWS June 4, 2013

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Contact Ultrasound – Slide 97 Full thickness wounds Ultrasound transmission gel to intact periwound and hydrogel to wound bed, then hydrogel sheet Partial thickness wounds Hydrogel sheet directly over the wound including 4-6 cm onto the periwound Cleanse applicator with antibacterial agent Ultrasound get on top of hydrogel sheet

(Suspected) Deep Tissue Injury DTI Purple or maroon localized area of discoloration Blood filled blister May evolve rapidly into a very bad pressure ulcer, or may not evolve at all Looks like a big bruise especially over a bony prominence.

(Suspected) Deep Tissue Injury

What we’ve covered Cleansing the wound Debridement Topicals Dressings PLWS, Syringe Lavage, Whirlpool Mechanical, Selective vs Non-Selective Topicals Dressings Contact Ultrasound Electrical Stimulation

Contact Low Frequency Ultrasound Ultrasound assisted wound therapy, ultrasound assisted debridement, Arobella, Qoustic Wound Therapy System Low frequency 20-40 kHz (vs 1-3 MHz) Non-thermal Creates cavitation Acoustic streaming

Contact Low Frequency Ultrasound Cavitation Creation of miniscule gas bubbles in the tissue fluid and coupling medium Bubbles expand/contract with variation in ultrasound field pressure levels Bubbles implode; tiny shock waves Necrotic tissue tensile strength < viable tissue Shock waves liquefy necrotic tissue, biofilm No major harm to tissue unless you concentrate on a single area

Contact Low Frequency Ultrasound Acoustic Streaming Movement of fluids along the acoustic boundaries Bubbles or cell membrane Increases cell membrane permeability Increases vascular wall permeability Increase protein synthesis

Cavitation and Acoustic Streaming Believed to be responsible for stimulatory effects of cells. Believed to modulate cell activity Increase cellular proliferation Increase collagen deposition* Increase growth factor activity Bottom line: Good for healthy cells* Bad for bacterial, senescent and devitalized cells

Contact Low Frequency Ultrasound http://www.youtube.com/watch?v=xl0tCZ5kDTY WARNING!!!!! Don’t eat before or during this video!!! Contact low frequency US provides Therapeutic and bactericidal effects

Contact Low Frequency Ultrasound Indications: All wounds that require debridement

Contact Low Frequency Ultrasound Benefits: Immediate results- removal of slough Selective Less painful that sharp debridement??? Considerations: $$$$, no “extra” reimbursement Can be painful Be careful, used for “excisional” debridement Debridement of living tissue Physician only! (not in scope of practice of PT) When performing this technique over living tissue, move the contact head more quickly so it doesn’t result in excisional debridement. Aerosolization and PPE

Contact Low Frequency Ultrasound Contraindications: All ultrasound contraindications Malignancy, cardiac area in CHF, etc. Untreated, advancing cellulitis Signs of systemic infection Metal components Electrical device within treatment area Uncontrolled pain: know what’s causing this! DVT, emboli (can break up clot and cause a stroke)

Non-Contact Low Frequency Ultrasound MIST Therapy Same principles as Contact Low Frequency Ultrasound No contact = no pain Reduces pain??? Can be used for maintenance debridement No harm to healthy tissue Disposable; 3-5 minutes total No aerosolization: mist does not come out at high enough PSI to create aerosolization MUST wear PPE Some patients reports less pain after MIST therapy, even though the FDA has not stated this technique is for pain relief

Non-Contact Low Frequency Ultrasound http://www.youtube.com/watch?v=dhfGMWmBhhc http://www.youtube.com/watch?v=Yi1hj7QCOeo Results in stimulated blood low and increased cell proliferation Cell walls of bacterial will crack open/break down and wash away. Hold tool perpendicular to the wound Be as close as possible without touching the applicator tip to the wound Intermittent bubbling may occur For wounds greater than 30 cm2 refill saline and monitor.

Non-Contact Low Frequency Ultrasound Indications: Suspected DTI (deep tissue injury that hasn’t opened up) Plus any wound Considerations: $$$$ (18-25K) CPT code coming January 1, 2014! (reimbursement to be determined still)

Non-Contact Low Frequency Ultrasound Contraindications Same as Contact Low Frequency Ultrasound Less concern with harming living cells because you are not in contact with the tissues

Debridement Removal of tissue or foreign material Indications: Conservative – removal of senescent, dead or devitalized tissue Aggressive or excisional – removal of living tissue Done by surgeon/physician in OR Indications: Any time there is something that needs to be removed!

Debridement Benefits Decrease bacterial load Stimulates growth factors Exposes cell receptors for growth factor interface Remove senescent cells Facilitate angiogenesis Allow full determination of depth and character of wound bed (which will help with setting a prognosis) Restart inflammatory or proliferation phase of healing

Debridement Considerations Pain Anticoagulants/Bleeding disorder Know your anatomy! If you don’t know, don’t remove! ABI? Some texts say not to do on anyone with ABI less than 0.5 because there may not be enough blood flow to support debridement Have to use good clinical judgment to determine whether to do this Think about what you are doing to increase circulation IF choosing to do this on someone with a low ABI If less than 0.7 send to see a vascular surgeon to see if they can get a stent, meds etc. EXPLAIN to the patient what you’re going to do to help minimize pt anxiety.

Debridement No – leave it alone! Granulation tissue Viable or potentially viable tissue Stable eschar (see picture) Dry gangrene Pyoderma Gangrenosum Muscle, tendon, ligament, capsule, fascia, nerves, blood vessels (things you need!) Intact blisters

Pyoderma Gangrenosum Poorly understood skin condition 1 in 100,000 (rare, but you will see in wound clinic) Wound that will Rapidly enlarge with trauma and debridement of wound bed (ie: removing a dressing that is stuck to the wound bed, etc) Unknown etiology Associated with inflammatory conditions (bowel disease, RA, immune disorders) 50% of cases are idiopathic Reoccurrence rate 30% Almost like an allergic reaction to dressing

Pyoderma Gangrenosum Typically lower legs Edges elevated with undermining Violaceous borders Looks similar to hemosiderin staining Cribiform scarring Criss cross scarring pattern Diagnosis by exclusion There is NOT test for this In normal wounds, undermining will be associated with flat wound edges, NOT raised!

Pyoderma Gangrenosum Treatment Months to years to heal If suspect, stop debridement and get to dermatologist ASAP! Wound will appear worse after first treatment Elevated edges will be worse Oral steroids Topical steroids, antibiotic and sometimes immunosuppressant Months to years to heal Because you cannot do debridement Steroids=delayed healing Get patient a non-adherent dressing and send them to a dermatologist!

Debridement We’ve already covered some: PLWS Syringe lavage Whirlpool Irrigation Selective vs Non-selective

Debridement Additional means: Enzymatic Debridement Autolytic Debridement Biological Debridement Sharp Debridement

Debridement What are we trying to do? Necrotic tissue Eschar (firm, thick) Slough (yellow, white, tan. Can be easy or hard to remove) Debris (dressing residue) Residual topicals Foreign material Callus DEFINITELY get rid of! Biofilm/Bioburden? Can’t see this but needs to be removed because it can cause infection Senescent cells Macerated tissue? Occurs when wounds get too wet.

Debridement Callus (yes) Blister (no) NEVER NEVER NEVER debride an intact blister no matter what it’s filled with Debride callus because it’s dead tissue that is building up uncontrollably 3 Problems with calluses: If callus grows over wound bed, you’re covering it with dead tissue and abcess will grow up into the body If it continues to grow uncontrollably, it forms a hard core in the center which can create a pressure ulcer under the callus (noted by the blood formation in the callus) If an open would and the callus is near the wound bed, it creates a donut around the wound (intense ring of pressure around the wound that can break down the wound bed)

Debridement Granulation tissue (no) Do NOT debride. This is viable living tissue!

Debridement Slough (yes) Need to remove so you can visualize the wound bed Slough can be very adherent and hard to remove Venous insufficiency wound ( heavy exudate) full of fibrin (protein)= very fibrous, adherent and hard to remove If you can’t remove with sharp debridement, you can cross hatch the top of the wound to help open up the slough Reveal as much of the wound bed as you can before you make a prognosis!

Debridement Slough (yes) Slough can also be very loose and easy to remove!

Debridement Stable eschar (no) Unstable eschar (yes) Stable: See pic. Firm. If you push on it, nothing oozes out from around the edges. If the edges are coming up, you can turn it back. Unstable: very boggy. Liquefied slough will ooze from around the wound if pushed on. This is a sign that debridement is needed!

Debridement Tendon (no) Look for striations! This is a TENDON! IMPORTANT!!! Keep exposed bone and tendon MOIST! Tendon will start to fray/bone will start to crumble if too dry!

Debridement Dry Gangrene (No) Looks a lot like stable eschar but is thicker, darker and harder. Will eventually shrivel up and fall off. Most patients don’t have sensation so it won’t bother them.